Fit For Duty? The Importance of Sound Mindedness in Clinical Practice
In a previous post we discussed cognitive bias and how our mind’s own natural way of thinking can lead us into mental traps. In that post we also noted another kind of vulnerability—cognitive deficits that also can impact our ability to make appropriate medical decisions. In this post I'd like to unpack the concept of cognitive deficits and introduce the concept of sound mindedness and its importance for clinical practice.
Clinicians are required to maintain a vast knowledge-base and skillset that constantly needs updating and fine-tuning. We appraise ambiguous clinical presentations and make rapid decisions, sometimes with inadequate information and under emotional stress.
We must come to terms with the fact that we are high-stakes knowledge workers and at the core of our best work is a sound mind.
Consider your mind operating at its most optimal condition. We would imagine a mind that is well rested, biochemically normal, undistracted, with clear thinking and well prepared for the task at hand. These are just some of the descriptors that would apply to a state of sound mindedness. Cognitive deficits may be thought of as any of the external or internal forces that diminish our capacity for sound mindedness and subsequently sound clinical decision-making.
Sound Mindedness is Well Rested
It is generally well accepted that a fatigued mind is, to some extent, an impaired mind. No one can guarantee that they will have a good night’s rest before a long shift or be able to change our schedule for an optimal sleep schedule. Nevertheless, every effort must be made to achieve the best sleep hygiene for the particular situation.
Emergency medicine clinicians struggle to obtain optimal sleep hygiene with ever-changing schedules.
Appropriate sleep is absolutely essential to the maintenance of normal neurochemistry.
Sound Mindedness is Well Focused
To focus on our high-stakes work we need to be clear thinking and undistracted. If we factor in the ubiquitous presence of distracting screens and high patient volumes, distractions are inevitable. Avoiding distractions and training ourselves to be well focused is a kind of professional skill that you have to maintain in order to be effective. Not all distractions are easy to overcome.
Some of the more powerful distractions are things that affect our sense of health and well-being.
Any acute pain, illness, or injury can be very distracting, and so clinicians should work with administration to have their patients cared for if they are distracted by physical impairment.
Another powerful form of distraction is strong emotion. Leaving the house after a fight with a loved one or a negative interaction with a patient or colleague can constantly pull our attention away from our complex patients and toward the nagging desire to resolve or reengage our source of negative emotions.
Conflicts and negative emotions can be complicated and not easily resolved. However, it is recommended that whenever it is within your power to mitigate the negative emotions by re-engaging with the source of those emotions even if it means just acknowledging their presence.
If I have a conflict with one of my nursing colleagues, I will try to find an appropriate time to engage them and do what I can to mend the relationship. A positive work environment is much more conducive to well-focused practice.
Sound Mindedness is Well Prepared
Most clinicians will tell you that though they are well prepared and enormously capable, they still have knowledge gaps.
If you are a human being it is inevitable that there will be some lacunae or gaps within your knowledge base or your skillset. Anyone who says otherwise is weird and dangerous.
Identifying these gaps and actively seeking out repair of those gaps is essential to ongoing quality assurance. Most of us starting out have an idea of where gaps are—for me it was obstetrics. I would rather take care of a heart attack any day than active labor.
So what does one do? Avoid all third-term pregnant women? Cherry pick the chart rack until you find a chest pain?
Your knowledge gaps are a threat to your patients’ well-being and it is your responsibility as a professional to repair those gaps.
Early on in our careers we will rely heavily on our collaborating physicians and other clinicians to help bridge those gaps and ensure that patients are receiving the standard of care. But we can’t rely on other professionals indefinitely. Our optimal value to the health system is predicated upon our optimal effectiveness. The better we get the more value we bring to healthcare in the US.
Sound Mindedness is Continuing Education
To repair knowledge gaps in our base and our skillset we need to be intentional about continuing medical education. I constantly make an inventory of my own knowledge gaps. Then I seek out high-quality CME opportunities that provide content on my identified knowledge gaps.
High-quality CME must engage you as a learner and provide an opportunity for you to show mastery of that content. CME boondoggles may get you a ticket to Maui but they’re not going to improve your knowledge base or skill set.
In addition to my ongoing inventory of knowledge gaps I have to recognize, as a human being, that there are things that I don’t even know I don’t know (wait what?). That is to say there are gaps in my knowledge base that I’m not even aware of.
To expose these hidden deficits, it’s good to have a CME opportunity that includes a comprehensive test experience. Take a practice test for the recertification exam and use this as a diagnostic test to expose areas of weakness that may be eluding your attention. This type of intensive work is the best way to repair knowledge gaps and develop a mind that is well prepared for clinical practice.
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